A condition affecting the inner ear which results in a triad of vertigo, hearing loss, and tinnitus.
Pathophysiology
- The underlying pathophysiology is not fully understood, but it is thought to be due to excessive volumes of endolymph in the inner ear, known as endolymphatic hydrops.
- This increased volume, and pressure, in the labyrinth is thought to cause dysfunction of the inner ear.
- It is thought that increases in pressure cause breaks in the membrane separating perilymph from endolymph, resulting in a mixture of the two fluids which cause inappropriate changes to nerve firing, thus causing vertigo.
Clinical Features
- Patients tend to get attacks of vertigo and tinnitus which tend to occur in clusters, with periods of remission between clusters of attacks. With time, these symptoms progress to become more permanent.
- Alongside this, there is a progressive sensorineural hearing loss.
- Symptoms usually begin between age 20-60, and tends to affect women more than men.
- Unilateral: Symptoms usually affect one ear.
- Vertigo: 20 minutes-12 hours. Can be associated with nausea/vomiting.
- Hearing loss: Sensorineural hearing loss, affecting low frequencies at first.
- Tinnitus: Can fluctuate, or can occur just before vertigo attacks. Become more persistent as the disease progresses. Usually a low-pitched sound.
- Fullness in the ear: May also precede vertigo attacks.
- Imbalance/unsteadiness: Can persist for some time following episodes of vertigo.
- Nystagmus during episodes.
- Tumarkin’s otolithic crisis/drop attacks: Sudden falls without loss of consciousness or preceding symptoms. A very rare manifestation of Meniere’s disease.
Investigations
Meniere’s is largely a clinical diagnosis, but audiology assessments are usually required to further assess the type of hearing oss.
Differential Diagnosis
- BPPV
- Acoustic neuroma
- Vestibular neuronitis
- Multiple sclerosis
- TIA
Management
Conservative
- Driving advice: DVLA advises that patients with a ‘liability to sudden and unprovoked or unprecipitated episodes of disabling dizziness’ should stop driving, and should inform the DVLA.
- General advice: Avoiding activities where sudden dizziness could be dangerous e.g. operating heavy machinery/climbing ladders etc.
Acute Attack
- Prochlorperazine (up to 7 days)
- Antihistamine: Cinnarizine or Cyclizine
Prevention
- Betahistine: Can be used to prevent attacks. It is first given as a trial – the evidence behind its efficacy is quite disputed.
References
https://emedicine.medscape.com/article/1159069-overview?form=fpf#a4
https://www.nhsinform.scot/illnesses-and-conditions/ears-nose-and-throat/menieres-disease/
https://www.intechopen.com/chapters/52996
https://www.semanticscholar.org/paper/Diagnosis-and-Management-of-Drop-Attacks-of-Origin%3A-Black-Effron/7dece29c8b2fe9a94008ab5fc9394de19502b27d/figure/0
https://dizziness-and-balance.com/disorders/central/drop.html
https://cks.nice.org.uk/topics/menieres-disease/management/management/
